Not a surgical vaccine: there is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia

An article published in the Australian and New Zealand Journal of Public Health, Volume 35, Issue 5, pages 459–465, October 2011. DOI: 10.1111/j.1753-6405.2011.00761.x

Objective: To conduct a critical review of recent proposals that widespread circumcision of male infants be introduced in Australia as a means of combating heterosexually transmitted HIV infection.

Approach: These arguments are evaluated in terms of their logic, coherence and fidelity to the principles of evidence-based medicine; the extent to which they take account of the evidence for circumcision having a protective effect against HIV and the practicality of circumcision as an HIV control strategy; the extent of its applicability to the specifics of Australia's HIV epidemic; the benefits, harms and risks of circumcision; and the associated human rights, bioethical and legal issues.

Conclusion: Our conclusion is that such proposals ignore doubts about the robustness of the evidence from the African random-controlled trials as to the protective effect of circumcision and the practical value of circumcision as a means of HIV control; misrepresent the nature of Australia's HIV epidemic and exaggerate the relevance of the African random-controlled trials findings to it; underestimate the risks and harm of circumcision; and ignore questions of medical ethics and human rights. The notion of circumcision as a ‘surgical vaccine’ is criticised as polemical and unscientific.

[Circumcision is] Irrelevant to Australia's HIV problem

The most serious objection to the circumcision proposal is that it is not applicable to our situation. Australia is not sub-Saharan Africa, where HIV is a generalised epidemic transmitted largely by heterosexual intercourse and non-sterile medical equipment. In Australia, HIV is a relatively low-prevalence disease, largely contained within the specific sub-cultures where it has always been found: mostly homosexual men (80%), plus a very small population of injecting drug users (4%). Although Daniel Halperin advised gay men who take the insertive role in anal intercourse to get circumcised, it is now firmly established that circumcision provides no protection to men who have sex with men (MSM), and there is evidence from Britain that circumcised gay men may be at greater risk. Whether that is generally the case, it is obvious that circumcision would have made no difference to the vast majority of Australian men who have become HIV positive over the past thirty years.

The proposal is also irrelevant because it targets infants rather than adults. Infants are not at risk of infection by sexual contact and will not be at risk until they become sexually active in 16–20 years time, by which time treatment and prevention options, and the virus itself, may have altered beyond recognition. Evidence-based medicine requires that recommendations for treatment or prophylaxis follow logically and directly from the evidence. Assuming the African evidence is reliable and applicable, the logical prescription is that sexually active adult men who have regular intercourse with numerous female partners and do not always use condoms should consider circumcision for themselves. One approach might be that sexual health advice targeted at this category could include circumcision as a prophylactic option among a range of sexual health offerings, as the WHO has recommended.

[Circumcision] Harm and complications

Two glaring omissions from Cooper et al's argument are discussions of the harm and risks of circumcision and the ethics of performing amputative surgery on minors. Research on the anatomy and physiology of the foreskin is primitive, but we know that it is an anatomically integral, sexually functional and psychologically significant component of the penis, loss of which may have adverse consequences on both sexual satisfaction and psychological well-being. The extent to which the foreskin contributes to sexual function is in dispute, but research is so inadequate that nobody can say with confidence that circumcision ‘makes no difference’. The RACP policy statement acknowledges that the foreskin is the most sensitive part of the penis and points out that since men may resent having been circumcised as infants, it may be preferable to delay the operation until a boy reaches maturity and can give informed consent. It might be assumed that resentment would be less if all boys were circumcised at birth, but even when they grow up among circumcised peers many men can still feel angry and mutilated, even to the point of psychological disturbance.

Complications from circumcision are another area where lack of both adequate data and benchmarks for acceptable risk make it impossible to be confident that the operation is ‘safe’. While all circumcisions result in the loss of the most sexually responsive portion of the penis, accurate estimates of the incidence and severity of complications are not available. In 2002 the RACP cited estimates ranging from an implausible 0.06% to an equally unlikely 55%, depending on definition, but regarded the likely incidence as falling somewhere between 2% and 10%, and warned that “serious complications, such as bleeding, septicaemia and meningitis may occasionally cause death”.

[Circumcision and] Unscientific language

While we all hope that a vaccine for HIV will eventually be developed, the tendency to describe circumcision hyperbolically as a ‘surgical vaccine’ is regrettable and misleading. The comparison may appeal to scientifically naive journalists, but it has no basis in science and is irresponsible from a public health perspective, in that it may encourage high-risk behaviour. Circumcision provides nothing like the kind or level of protection provided by a vaccine.

Who is this guy?

Restoring Tally is just an ordinary guy who had to confront his prostate and circumcision problems. This site chronicles his journey in dealing with these issues. He has had prostate surgery and he is restoring his foreskin.